Basic Information
| Provider Information | |||||||||
| NPI: | 1629511225 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERZOG | ||||||||
| FirstName: | BRITTNEY | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1604 ROCKY FORD RD | ||||||||
| Address2: | |||||||||
| City: | PONTOTOC | ||||||||
| State: | MS | ||||||||
| PostalCode: | 388638667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6124016130 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6019 WALNUT GROVE RD | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381202113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012265000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2016 | ||||||||
| LastUpdateDate: | 02/17/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 882835 | MS | N | Nursing Service Providers | Registered Nurse | 367500000X | 22133 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.